Minimally Invasive Cubital Tunnel Release Utilizing Lighted Retractors: A Study of Residents Novel to this Technique Utilizing a Cadaveric Model.

The purpose of this study was to evaluate whether a minimally-invasive cubital tunnel release using lighted retractors could be performed safely and completely by residents with no prior training in this technique. Ten residents participated in the study. Postoperative dissection of the specimens was performed utilizing a detailed checklist and global rating scale to evaluate the completeness of release as well as presence of neurologic injury. Performance of residents was compared. Rho correlation analysis was used to verify validity of the assessment tools. Training year most strongly correlated with Global Rating Scale assessment values. There was a trend correlating training year with faster surgical times, and Detailed Checklist scores. Validation measurements showed strong correlations between the pass/fail grade and the Detailed Checklist and the Global Rating Scale. Complete release of the ulnar nerve in situ utilizing lighted retractors can be performed with minimal training or experience. (Journal of Surgical Orthopaedic Advances 32(3):193-198, 2023).

Venous Flaps for Revascularization and Soft-Tissue Coverage in Traumatic Hand Injuries: A Systematic Review of the Literature.

BACKGROUND: The use of the venous flap for simultaneous revascularization and coverage of soft tissue defects has been documented in the literature for over 30 years. First described in 1981, Nakayama et al demonstrated that a vein and overlying skin, or a venous flap, may be transposed from one area of the body to another with complete survival of the graft. The aim of this study was to conduct a systematic review of the literature to determine predictors of venous flap survival in traumatic hand injuries. METHODS: A literature search of PubMed, MEDLINE, and Cochrane Library was performed with emphasis on venous flap use in traumatic hand injuries. MeSH terms included: vein graft, revascularization, venous flow through flap, arterialized venous flap, bypass, replantation, amputation, avulsion, trauma, injury, amputate, finger, hand, and thumb. RESULTS: Forty-three articles were collected that contained data on 626 free venous flaps. Most patients were males (73.9) and injured their right hand (52.3%). The forearm was the most commonly used venous flap donor site (83.6%), and most of the skin paddles were 10 to 25 cm2 (41.1%). Arterial inflow was used in 93.1% of the flaps. Most venous flaps (79.6%) healed without superficial tissue loss or necrosis. Ninety-two (14.7%) flaps had partial loss while 36 (5.8%) flaps did not survive. CONCLUSION: The use of venous flaps for concomitant revascularization and soft tissue coverage of the hand permits good results with limited morbidity. The overall flap survival rate is nearly 95%. Younger patients whose flaps have arterial inflow and skin paddles of medium size (10-25 cm2) have the best chance for survival.

Salve and Burdock: A Safe, Effective Amish Remedy for Treatment of Traumatic Wounds?

BACKGROUND: Amish patients show a demonstrated preference for traditional, herbal remedies over modern medical interventions such as skin grafting. One such remedy is a mixture of Burn & Wound Ointment (B & W Ointment; Holistic Acres, LLC; Newcomerstown, Ohio) and steeped burdock leaves. Although both have demonstrated some antimicrobial and wound healing properties, burdock and/or the combination of B & W Ointment and burdock has never been studied to determine its purported ability to reduce pain, prevent infection, and accelerate wound healing. METHODS: A retrospective chart review was performed on 6 Amish patients treated with salve and burdock leaves instead of skin grafting following complex traumatic wounds to determine whether the traditional treatment incurred any patient harm. RESULTS: The time of wound epithelialization and healing complications were noted, among other data points. Time to full epithelialization ranged from 1 to 7 months. Time to full wound healing was proportional to wound size. CONCLUSIONS: Although the treatment presented here is unconventional, it did not cause harm to the patients studied.

Prospective, randomized evaluation of endoscopic versus open carpal tunnel release in bilateral carpal tunnel syndrome: an interim analysis.

BACKGROUND: Most randomized trials have shown similar results with endoscopic carpal tunnel release (ECTR) and open carpal tunnel release (OCTR); however, there are studies suggesting less postoperative pain, faster improvement in grip and pinch strength, and earlier return to work with the endoscopic technique. The goal of this study was to prospectively examine subjective and functional outcomes, satisfaction, and complications after both ECTR and OCTR in the opposite hands of the same patient, serving as their own control. METHODS: This was a prospective, randomized study in which patients underwent surgery for bilateral carpal tunnel syndrome. The first carpal tunnel release was performed on the most symptomatic hand-determined by the patient. Operative approach was randomly assigned and, approximately 1 month later, the alternative technique was performed on the contralateral side. Demographic data were obtained, and functional outcomes were recorded preoperatively and postoperatively, including pain score, 2-point discrimination, Semmes-Weinstein monofilament testing, thenar strength, and overall grip strength. The carpal tunnel syndrome-functional status score and carpal tunnel syndrome-symptom severity score were recorded before surgery and at 2, 4, 8, 12, and 24 weeks postoperatively. Overall satisfaction with each technique was recorded at the conclusion of the study. RESULTS: Currently, 25 subjects have completed final visit testing. There were no differences in pain score, 2-point discrimination, Semmes-Weinstein monofilament testing, thenar strength, or overall grip strength at any of the postoperative time points. Carpal tunnel syndrome-symptom severity score and carpal tunnel syndrome-functional status score were not significantly different between groups at any of the evaluations. Overall satisfaction, where patients recorded a number from 0 to 100, was significantly greater in the ECTR group (95.95 vs 91.60, P = 0.04). There were no complications with either technique. DISCUSSION: This interim analysis, using the same patient as an internal control, suggests that both OCTR and ECTR are well tolerated with no differences in functional outcomes, symptom severity and functional status questionnaires, or complications. Although there were no differences between groups using our study metrics, patients still preferred the ECTR, demonstrated by significantly higher overall satisfaction scores at the conclusion of the study.

Surface wear of PyroCarbon implant in metacarpophalangeal joint arthroplasty without radiographic abnormality: A case report.

CASE: A 54-year-old male with osteoarthritis of the right long finger metacarpophalangeal joint underwent PyroCarbon joint arthroplasty. Seven years later the patient presented for metacarpophalangeal joint swelling and pain. The workup was benign, without signs of implant complication or osseous abnormality. He underwent washout and two-stage revision, where gross implant wear and debris not demonstrated by radiograph were found. He then returned to the operating room for reimplantation of a PyroCarbon implant. CONCLUSION: This case demonstrates a novel presentation of aseptic PyroCarbon implant failure in the hand without radiographic abnormality that can alter operative management by reducing operating room returns.

The use of prophylactic antibiotics in plastic surgery: update in 2010.

BACKGROUND: The indications for prophylactic antibiotics in plastic surgery remain controversial. No recent survey has been reported on the use of prophylactic antibiotics by plastic surgeons in clinical practice. This survey was designed to assess the current use of prophylactic antibiotics by plastic surgeons and to compare trends with previous studies. METHODS: All members of the American Society of Plastic Surgeons with an e-mail address on the Society's website were contacted via an e-mail and sent a link to a SurveyMonkey questionnaire. To survey only in those subspecialty areas that they practice in, surgeons were queried only on the procedures that they perform. Within each section, a list of common representative procedures was included, with questions about the use of antibiotic prophylaxis. RESULTS: A total of 3824 American Society of Plastic Surgeons members were contacted. Of the 3613, 910 with working e-mail addresses responded to the survey for a response rate of 25%. And 833 or 91.5% completed the survey. Survey data cover the percentage of surgeons reporting their use of antibiotics in procedures that they currently perform. The percentage of plastic surgeons who use prophylactic antibiotics in almost all procedures studied has increased significantly when compared with earlier studies. CONCLUSIONS: The use of prophylactic antibiotics by plastic surgeons has increased considerably since the prior studies by Krizek et al (Plast Reconstr Surg. 1975;55:21-32 and 1985;76:953-963). Some of these uses are appropriate because of the use in procedures involving implants and longer operations. The elevated rates for clean procedures are not part of the evidence-based practice.

Acute limb shortening or creation of an intentional deformity to aid in soft tissue closure for IIIB/IIIC open tibia fractures.

BACKGROUND: Ring fixator techniques can precisely correct complex long bone deformities. In select patients, controlled shortening or intentional fracture deformation with delayed correction can also aid in complex wound coverage and limb salvage. METHODS: This retrospective cohort study analyzed all patients who underwent acute limb shortening or intentional temporary fracture deformation between 2005 and 2020. Patients were divided into three groups based on reason for acute shortening or intentional deformity: (1) skeletal indications alone, with traditional flap coverage; (2) skeletal and soft tissue indications, to augment traditional reconstructive measures; and (3) skeletal and soft tissue indications, to avoid microsurgery altogether. Comorbidities, orthopedic and reconstructive methods, and functional outcomes were recorded. RESULTS: Eighteen patients were identified: six in Group 1, five in Group 2, and seven in Group 3. Fractures were primarily in the distal third of the tibia. On initial assessment, all wounds would have required free tissue transfer. Group 1 patients were reconstructed with free flaps. Among Group 2, closure was accomplished by skin grafting (N = 1), local flaps (N = 1), pedicled muscle flaps (N = 1), and free flaps (N = 2). In Group 3, five wounds were closed primarily and two were skin grafted. All limbs were shortened, averaging 25.1 mm; seven were intentionally deformed, most commonly varus (10-20°). After skeletal correction, residual leg length discrepancy averaged 5.7 mm. No patients required amputation. CONCLUSIONS: Acute skeletal shortening with or without intentional temporary deformation in select IIIB/IIIC open tibial fractures can facilitate soft tissue coverage and limb salvage in patients who might otherwise require amputation.

A Prospective, Randomized Trial Comparing Open and Endoscopic Carpal Tunnel Release Within the Same Patient.

Background: Surgical management of carpal tunnel syndrome includes performing an endoscopic (ECTR) or open (OCTR) carpal tunnel release. Several studies have shown less postoperative pain and improvement in grip and pinch strength with the endoscopic technique. The goal of this study was to prospectively examine outcomes, patient satisfaction, and complications after both ECTR and OCTR in the opposite hands of the same patient. Methods: This was a prospective study in which patients with bilateral carpal tunnel syndrome underwent surgical release with both techniques, with initial operative approach randomized in the more symptomatic hand. Demographic data and functional outcomes were recorded, including the pain score, 2-point discrimination, Semmes-Weinstein monofilament testing, thenar strength testing, grip strength, carpal tunnel syndrome functional status score, carpal tunnel syndrome symptom severity score, and overall satisfaction. Results: Thirty patients completed the study; there were no significant differences in any measure at any of the postoperative time points. Symptom severity and functional status scores were not significantly different between groups at any evaluation. Subjectively, 24 of 30 patients did state they preferred the ECTR, mostly citing less pain as their primary reason, although pain scores were not significantly different. Differences in overall satisfaction were also not significant. Conclusions: Both techniques are well tolerated with no differences in outcomes. With the added cost and equipment associated with ECTR, and no added benefit, the usefulness of ECTR is questionable.

Direct Cost Comparison of Open Carpal Tunnel Release in Different Venues.

Background: The increased efficiency and cost savings have led many surgeons to move their practice away from the traditional operating room (OR) or outpatient surgery center (OSC) and into the clinic setting. With the cost of health care continuing to rise, the venue with the lowest cost should be utilized. We performed a direct cost analysis of a single surgeon performing an open carpal tunnel release in the OR, OSC, and clinic. Methods: Four treatment groups were prospectively studied: the hospital OR with monitored anesthesia care (OR-MAC), OSC with MAC (OSC-MAC), OSC with local anesthesia (OSC-local), and clinic with local anesthesia (clinic). To determine direct costs, a detailed inventory was recorded including the weight and disposal of medical waste. Indirect costs were not included. Results: Five cases in each treatment group were prospectively recorded. Average direct costs were OR ($213.75), OSC-MAC ($102.79), OSC-local ($55.66), and clinic ($31.71). The average weight of surgical waste, in descending order, was the OR (4.78 kg), OSC-MAC (2.78 kg), OSC-local (2.6 kg), and the clinic (0.65 kg). Using analysis of variance, the clinic's direct costs and surgical waste were significantly less than any other setting (P < .005). Conclusions: The direct costs of an open carpal tunnel release were nearly 2 times more expensive in the OSC compared with the clinic and almost 7 times more expensive in the OR. Open carpal tunnel release is more cost-effective and generates less medical waste when performed in the clinic versus all other surgical venues.

Is the tendon embryogenesis process resurrected during tendon healing?

The process of embryonic tendon development, including the nature and purpose of collagen fibril segments, is reviewed. It is proposed that tendon fibrillogenesis of repair is related to the fibrillogenesis of tendon embryonic development. The assembly of collagen fibril segment units into longer fibers occurs on the surface of tendon fibroblasts in embryonic tendon development. The biochemist's view of tendon healing, whereby the spontaneous polymerization of tropocollagen monomers regenerates lost tendon collagen fibers, needs to be reconsidered. Furthermore, the importance of direct fibroblast involvement in collagen fiber reassembly during tendon healing needs to be studied in tendon intrinsic regenerative repair.

Pulp nonfiction: microscopic anatomy of the digital pulp space.

The volar pad of the fingertip provides a very stable yet sensitive surface that gives the hand the ability to pinch and grasp. The focus of this study was to advance understanding of the anatomical features of the digital pulp space. The unusual features of the fingertip pulp space include prominent collagen fiber cords and a branching continuous fine vasculature. Prominent collagen fiber cords radiating out from beneath the epidermal basement membrane are like the cords of a parachute, which directly attach to the periosteum of the distal phalanx. Those collagen fiber cords are responsible for the firm attachment of the fingertip to the distal phalanx. There is a fine patent vasculature within the pulp space. Also contained in the capsule are numerous lobules of fat, which contribute to some elasticity of the fingertip. Principles of treatment for injuries or infections of the digital pulp should attempt to preserve this anatomical construct so that the firmness and vascular supply of the fingertip are maintained and not disrupted.

Dynamic changes appearing in collagen fibers during intrinsic tendon repair.

Intrinsic healing of severed tendons shows a delay in a gain in breaking strength and the tendon becomes translucent. The cause of tendon translucence was investigated in suture-repaired rat Achilles tendon. The repair site with adjacent translucent tendon were evaluated histologically on day 10 by immunofluorescence and transmission electron microscopy. The healing tendon translucent region by hematoxylin-eosin staining had few inflammatory cells, polarized light birefringence showed thinner collagen fibers, immunofluorescence showed few myofibroblasts, and transmission electron microscopy revealed frayed, irregular thin collagen fibers. During embryogenesis, tendon fibers grow by the addition of discreet collagen fibril segment structures. The speculation is that collagen fibril segment structures are released from collagen fibers within the translucent tendon region for reuse during the regeneration of tendon collagen fibers during intrinsic tendon repair. Healing tendon translucence is related to a decrease in the diameter of collagen fibers by the release of collagen fibril segments within tendon bundles/fascicles.

Intraosseous ganglion of the lunate.

Intraosseous ganglia are occasionally found affecting the carpal bones of the hand and should be considered in the differential diagnosis of chronic wrist pain. They have characteristic radiographic findings of a cyst with a thin sclerotic rim. This case report illustrates an unusual presentation of a cyst in the lunate with successful treatment. Standard of care includes curettage and bone grafting with minimal recurrence reported.

Systemic vanadate ingestion modulates rat tendon repair.

The chronic ingestion of vanadate prevents the appearance of myofibroblasts within granulation tissue of full excision wounds in rats, yet these wounds close at an optimal rate. Myofibroblasts are reported in the repair of transected tendons. Here we investigate tendon repair in the absence of myofibroblasts. Vanadate in saline drinking water was given to rats in the experimental group, while rats in the control group received saline alone. The Achilles tendon of the left leg of each rat was transected and suture repaired. On day 10, both repaired tendons and uninjured tendons from the right leg were harvested and processed for histology. By immunohistology the repaired tendons of control rats had myofibroblasts (fibroblasts with alpha smooth muscle actin positive stress fibers), while myofibroblasts were absent in healing tendons from vanadate-treated rats. By transmission electron microscopy and polarized light optics, repaired tendons of control rats demonstrated thin, loosely packed, immature collagen fiber bundles. Collagen fiber bundles from healing tendons of the vanadate-treated group were thicker, uniformly packed, and more mature. The chronic ingestion of vanadate promotes the more rapid organization of collagen fiber bundles of healing transected tendons in the absence of myofibroblasts.